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Dexamethasone
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Intravenous immunoglobulin
Observation
Rituximab
Splenectomy
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This patient with a sudden onset petechial rash and thrombocytopenia after an upper respiratory illness most likely has immune thrombocytopenic purpura (ITP). Children with ITP and platelets > 50,000/mm^3 can be treated with observation.ITP is a disorder where antibodies directed towards platelet membrane proteins such as GPIIb/IIIa lead to platelet consumption by splenic macrophages, resulting in thrombocytopenia. It often follows a viral illness. In most cases, patients present with diffuse petechia or purpura and are otherwise well. For these patients, the treatment is observation only, as the disease is often self-limiting. However, pediatric patients presenting with bleeding/hemorrhage and adult patients with platelet counts under 50,000/mm^3 should be managed medically. Initial pharmacologic management should begin with either a single dose of IVIg or a short course of oral corticosteroids. Failure of initial pharmacologic management could include rituximab. Splenectomy is indicated for patients who have failed all medical management.Baronci et al. review the evidence regarding the treatment of ITP in children. They discuss how this disease usually remits in most children, but that some will require treatment. They recommend splenectomy in refractory cases.Figure/Illustration A is a clinical photograph that demonstrates a petechial rash on the skin (red circle). This rash can be seen in patients who have thrombocytopenia.Incorrect Answers:Answer 1: Dexamethasone is an initial pharmacologic agent for patients who have symptomatic bleeding and a platelet count < 50,000/mm^3. In this patient who is otherwise well and has a platelet count above this threshold, simple observation is sufficient.Answer 2: IVIg may be used to manage patients with ITP presenting with mucosal bleeding or hemorrhage, or adult patients with platelet counts under 20,000/mm^3 regardless of symptoms. Answer 4: Rituximab is an antibody directed against CD20 that may be used as a second-line pharmacotherapy for patients who have failed initial medical management.Answer 5: Splenectomy is only indicated for patients who have failed all forms of medical management.Bullet Summary: Children with ITP and platelets > 50,000/mm^3 without bleeding can be observed.
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